Q&A with Haywood ER doctors

Haywood Emergency Physicians held a two-hour town hall style meeting Tuesday night to answer questions about the termination of their contract by Haywood Regional Medical Center.

“The emergency department is the health care safety net in this community as it is in communities across the country,” Dr. Mark Jaben with Haywood Emergency Physicians told an audience of about 75 people. “I think this community should be commended for taking ownership in this issue. This struggle at its core is about how the hospital makes decisions that impact health care in the community.”

Here’s an overview of the question-and-answer session. Hospital administration and the hospital board were invited to be part of the forum, but did not attend. These answers are the perspective of Haywood Emergency Physicians.

Q: Hospital administration said Haywood Emergency Physicians asked to open contract negotiations. Is that true?

A: The ER doctors current contract runs through May 2008. The ER doctors had been told by hospital CEO David Rice there was “no way” the hospital would renew the contract with Haywood Emergency Physicians when the current contract expired.

In the spring, the group lost three physicians, leaving only 10 doctors to staff the ER. The group wanted to recruit more doctors, but could not in good faith ask a doctor to relocate their family to this community when the contract’s future beyond May 2008 was unstable.

“We felt we were intentionally kept on the edge of not knowing if we were going to have a job when the next contract came around,” said Dr. Ely Zaslow. “We felt like how could we recruit other doctors when two years from now you might not have a job.”

So Haywood Emergency Physicians asked the hospital to extend their current contract to aid their recruitment efforts.

Q: How did the hospital respond to your request for a contract extension?

A: Three months went by with no word from hospital administration. In late August, Haywood Emergency Physicians was received an entirely new contract from the hospital and was given 60 days to accept the terms of the new contract or face termination.

“It became very clear to us at that time that this wasn’t going to be a negotiation but a dictation of terms,” Dr. Tom Sither said.

Q: What happened over the next 60 days?

A: Haywood Emergency Physicians met with Rice to discuss the new contract he’d proposed. Rice refused to tell the doctors what issues he had with their performance, prompting the threat of termination. A second meeting between the doctors and Rice was scheduled, but Rice’s attorney canceled the meeting. The emergency room doctors sent two letters to Rice asking him why their contract was being rewritten. They never got a response.

Q: Did the ER doctors attempt to communicate with the hospital board?

A: When the ER doctors were unable to get a second meeting with hospital administration and their letters went unanswered, the ER doctors asked to meet with the hospital board. They were still trying to find out why the hospital wanted to rewrite their contract. They wanted to know what issues Rice and the board had with the doctors and how those could be addressed.

But when they met with the hospital board, the board members would not answer their questions either.

“We hoped for a question-and-answer period so we could answer any questions the board had. But they were instructed not to ask any questions. We were later accused of not negotiating, but on two occasions our attorneys sent a letter asking for clarification and we weren’t responded to and when we tried to meet with the board they didn’t respond,” Sither said.

Zaslow said it was very disappointing. They could not address concerns the hospital board and Rice had if they weren’t told what those issues were.

Q: What happened when the medical community attempted to communicate with the board on the ER doctors behalf?

A: At a countywide meeting of doctors in November, physicians voted to ask for a meeting with the hospital board to discuss concerns they had. At that point, the hospital board had not yet voted to terminate the current ER doctors’ contract. Two hours before the scheduled meeting, Rice called the hospital board members and told them the meeting would violate the state Open Meetings Law. If a majority of board members on a public body convene to discuss public affairs, it must be announced as a public meeting. If the hospital had announced the meeting 48 hours in advance, it would have been OK. But instead of announcing the meeting to make it legal, Rice called it off at the last minute. About 45 doctors showed up at the meeting expecting to meet with the hospital board, but only three members of the board were there.

Zaslow said Rice pulled a “fast one at the 11th hour.”

“We saw that as our big chance,” Zaslow said. “We had hoped to communicate with them. It was recognized for what it was: a deliberate attempt to sabotage our meeting with the board,” Zaslow said.

Q: Hospital administration has cited several issues in the media about problems with Haywood Emergency Physicians. Were you aware of those?

A: “When things started coming out of the paper, it was a revelation to us. It was things that were never talked about in the contract discussions,” Jaben said.

“They would not clarify these issues with us,” Sither said.

Zaslow said it seemed Rice’s aim was to get rid of Haywood Emergency Physicians at all cost.

“His agenda is to get rid of us and has been to get rid of us,” Zaslow said. “It’s not about the shifting list of things you hear.”

In the wake of public outcry, hospital administration has attempted to justify the decision with various “sticking points” they allegedly have with Haywood Emergency Physicians but failed to mention in the context of contract talks and give the doctors a chance to address them, Zaslow said.

“The major sticking point has been a very elusive phenomenon. There have been five or six so-called major sticking points. None has the hospital been able to latch on to or defend for any length of time,” Zaslow said.

Q: Hospital administration said the contract had to be rewritten because of some IRS thing. What’s that about?

A: An obscure IRS law says that non-profit hospitals with tax-exempt bonds can’t have contracts with private businesses longer than three years. The law is supposed to keep hospitals from being a non-profit shell that funnels tax-free money into private practices. Haywood Emergency Physicians was in the midst of a five-year contract, and contracts are only supposed to be for three years.

This argument was disingenuous, however, say physicians with HEP. For starters, Haywood Regional does not currently have any bonds, so the law doesn’t apply.

Q: Hospital administration said the contract had to be rewritten because of some Medicare and Medicaid thing. What’s that about?

A: “That was never brought up in negotiations, but the board has cited it as the main sticking point since then,” Jaben said.

Jaben said the first he heard of that issue was at a meeting of medical executive meeting three weeks ago. Hospital board member Dr. Nancy Freeman said the ER doctors would not agree to language in the contract required for Medicare and Medicaid quality control initiatives. Jaben replied that if that was truly the board’s concern and all that was needed to make the contract work, the doctors would take care of it the next day.

Q: Hospital administration said the contract had to be rewritten because they were unhappy with patient wait time in the ER. What’s that about?

A: The wait time in Haywood’s ER is better than the industry average for like-sized hospitals, said Sither, holding up statistics he had brought to the meeting. Nonetheless, there’s nothing wrong with trying to improve patient wait time, so the doctors participated in an ER oversight committee whose top initiative was improving patient wait time.

There are many factors in patient wait time. There’s other departments like lab and radiology that factor into a patient wait time. One of the biggest hang-ups is the time it takes to get an ER patient transferred out of the ER into ICU or the main wing of the hospital after an ER doctor has stabilized them. It takes more than two hours on average to get the patient transferred, which ties up a bed for that time.

“That’s what has been perplexing to us over the past two years,” Sither said. “We have been repeatedly singled out as the primary culprits for a person’s length of stay in the ED.”

Q: What is the top need to reduce turnover time in the ER?

A: The top factor is not enough nurses, say the doctors. The hospital is responsible for staffing the ER with nurses, while Haywood Emergency Physicians provides the doctors. The hospital is providing fewer nurses than the industry standard calls for. When the ER doctors asked the hospital to increase nursing staff, Rice said it would cost too much.

“The nurses in our Emergency Department are stretched too thin. There are times they are running around like chickens with their heads cut off just trying to keep it together. They work extremely hard,” Jaben said.

On paper, nursing levels might seem OK. But out of six nurses on shift, two could be traveling nurses who just arrived, or two could be new graduates who are still in orientation, Sither said.

“We have great nurses but our turnover has been high and that’s disconcerting to us,” Sither said.

Q: Does the new $5 million ER work any better than the old one?

A: No. The old ER had 11 rooms and three stretchers in the hall. The new ER has 14 rooms that are in use — the same amount of beds as the old ER. The computer system is cumbersome and clunky and takes longer than the computer system in the old ER. The new ER had a decentralized design intended to use a paperless medical records system that allowed nurses to do charts at computer terminals in the halls and patient rooms. But the computer system is so bad that paperless medical records aren’t possible, so nurses and doctors are still running paper charts back and forth in a space that was not designed for centralized nurses station.

Despite little improvement in the space or efficiency, a worse computer system and no additional staff, the new ER is seeing 25 percent more patients than the old ER.

“We should be commended for keeping it on course as much as we have,” Jaben said.

The ER has three rooms that the hospital won’t open because there’s not the nursing staff to cover the rooms and Rice said the volume doesn’t justify opening the additional rooms, the doctors said. The Haywood ER is seeing 1,900 patients per bed per year. The industry standard is 1,650 patients per bed per year.

Q: The hospital administration has said ER doctors didn’t participate in the ER oversight committee to improve ER operations. Is that true?

A: No. Two ER doctors were appointed to be on the committee and take initiatives back to the rest of the practice. One of the two doctors was at every meeting except one.

“Why would we not try to make improvements? This is our only business. It’s how we support our families. Why would you stay somewhere 20 years and not want it do be as good as it can be?” Jaben asked.

Q: Hospital administration has said the ER doctors would not participate in developing protocols. What is this about?

A: Protocols tell a nurse how to handle patients with certain symptoms as soon as they walk in a door. For example, give Aspirin right away to someone with chest pain, or go ahead and order an X-ray for someone with a clearly broken arm.

The ER doctors do have protocols for these, so they don’t understand what the hospital administration is talking about. In fact, some of their protocols are being heralded as models for other hospitals. When Asheville Cardiologists asked Haywood Emergency Physicians to work on new protocols for transferring heart attack patients, they set a goal of getting a patient to the heart center with a balloon up their artery within 90 minutes. Within two months, the ER doctors had instituted protocols that had the time down to 60 minutes. The state medical board visited to see how they were doing it.

“They praised our Emergency Department as an example for the state as a way for getting this stuff done,” Jaben said.

Q: The hospital is supposedly saving money with the new group. How?

A: Emergency departments are required by law to treat every patient that walks in the door, regardless of whether they can pay. About 25 percent of the 26,000 patients the Haywood ER gets every year can’t pay. The hospital compensates the doctors for some of those indigent patients to the tune of $18,000 a month. That money allows the ER to have more doctors on board than they could afford otherwise.

“That money allows us to have more coverage in the emergency department than is currently the industry standard,” Jaben said of the indigent care reimbursements from the hospital. “It allows us to have doctors that aren’t so burned out and can spend more time talking to patients.”

The hospital will not be paying the new corporate group that $18,000 a month for indigent care. So the corporate group will not be able to afford as many doctors. As a result, the doctors won’t stick around for long, say the doctors with Haywood Emergency Physicians has.

“I think what you’ll see with Phoenix is competent doctors that won’t stay very long,” Jaben said. “There will be a revolving door of faces.”